Paying for Skilled Nursing Care: Medicare & Medicaid

Confusion often reigns when one learns that a family member will likely need long-term skilled care. Finances are always an issue. With the average stay in a local nursing home running $11,000 per month, our New York elder law attorneys are acutely familiar with the financial challenges facing local families at these times. Few can afford to pay those costs out of pocket. Without long-term care insurance (expensive in its own right), most families instead turn to Medicare and Medicaid for support.

Many seniors on Medicare get understandably confused when trying to determine what long-term care is provided by the program. The short answer is: very little. The Centers for Medicare and Medicaid Services have produced a handbook entitled Medicare Coverage of Skilled Nursing Facility Care which is a good starting point for those hoping to learn more. In general, the takeaway is that Medicare will only pay for certain skilled nursing stays and never for those staying longer than 100 days. The first 20 days of qualifying care are covered completely, while anything more (up to 100 days) often requires some sort of copayment. To even qualify for that care a resident must have a qualifying hospital stay, need the care immediately after the hospital stay, and meet a few other requirements.

Conversely, Medicaid is the joint state and federal program that provides the most support for extended nursing home stays. That is why on the elder law side of our practice our New York Medicaid attorneys work closely with local seniors to help them apply for the program and save their assets from being consumed in the qualification process. Unlike Medicare, Medicaid is an income-based program, meaning that local seniors will have to show specific financial need before receiving the help. The application process which takes all of this into account has complex asset and transfer rules. Because it is a joint state and federal program, the qualification process is different in each state.

There are actually two forms of Medicaid: Community and Chronic Care. As the name implies, Community Medicaid is much different in that it provides certain resources for individuals who wish to remain at home in their community. When that is no longer an option and close nursing home care is needed, then Chronic Care Medicaid comes into play. It is this form of Medicaid that has a “five year look back” period for assets and transfers. That means that if assets–a home, stocks, savings accounts–were handed over to another within that period, the value of those transfers may take the form of a penalty period where Medicaid services will not be provided. However, there are various strategies that can be employed to protect against the loss of all of one’s assets while qualifying for Medicaid. This is true even if one is on the nursing home doorstep. Professionals in the area will be able to explain those strategies and decide on the right course in your case.